Planner Conflict of Interest Disclosure

Planner Name:*

Planner Title and Institution:*

Title of CE Program:*

Title of Committee:*

Date of Activity:*

Known Commercial Supporter(s):

Per ACPE, all persons in a position to control the content of this educational activity (either as a planner or content expert/presenter/speaker) must disclose to CE SYNERGY, LLC any relationship of a financial, professional, or personal nature with an ineligible company from the past 24 months. The definition of an ineligible company is as follows: those whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

The intent of this disclosure is not to prevent a planner with affiliations to an ineligible company from planning an educational activity, or to prevent a presenter/speaker with affiliations to an ineligible company from presenting, but rather to inform CE SYNERGY, LLC as the accrediting provider, of any potentially biasing relationships so that conflicts can be mitigated prior to the activity.

It is the policy of CE SYNERGY, LLC to ensure balance, independence, objectivity, and scientific rigor in all of its continuing pharmacy education activities. CE SYNERGY, LLC will identify, determine, and if necessary, mitigate, all conflicts of interest. Prior to the time of the presentation, all relevant conflicts of interest will be disclosed to the audience in writing.

Please specify the categories below where any financial, professional, or personal relationship(s) exists.

1. Employment:*

Yes, I have an employment relationship.No, I don't have an employment relationship.

If yes, describe the relationship:

2. Elected or voluntary leadership position in professional organization, including committee membership*

Yes, I have a professional organization relationship.No, I don't have professional organization relationship.

If yes, list the organization name and position:

3. Research Funding:*

Yes, I receive research funding.No, I don't receive research funding.

If yes, describe the relationship:

4. Paid Consultant or Member of an Advisory Board or Review Panel:*

Yes, I am a paid consultant or member.No, I am not a paid consultant or member.

If yes, describe the consultancy or membership:

5. Speaker's Bureau:*

Yes, I am on a speaker's bureau.No, I am not on a speaker's bureau.

If yes, describe the speaker's bureau(s):

6. Major Stock or Investment Holder*

Yes, I have stock holdings.No, I don't have stock holdings.

If yes, describe the stock holdings:

7. Other Renumeration (Please list relationships and company name)

Signature*

Date*

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